Manual Claim Form
- Use this form to submit claims where you were unable to use your Healthy Dollars card or for prior year claims.
Online Account Set Up Instructions
- To set up your online account to view balance and claims history.
Dependent Care Continual Reimbursement Form
- Complete this for multiple payments to your care provider.
** Please submit this form to your HR department or payroll manager.
Dependent Card Request Form
- To order an additional card for your dependents.
** Please submit this form to your HR department or payroll manager.
Enrollment Form - Dependent Care
- To enroll in a Dependent Care Account (DCA).
** Please submit this form to your HR department or payroll manager.
Enrollment Form - DCA & FSA
- To enroll in both a DCA (Dependent Care Account) and FSA (Flexible Spending Account).
** Please submit this form to your HR department or payroll manager.
Enrollment Form - HRA
- To enroll in an HRA (Health Reimbursement Account).
** Please submit this form to your HR department or payroll manager.
Enrollment Form - HRA/FSA/DCA
- To enroll in an HRA (Health Reimbursement Account), FSA (Flexible Savings Account) and DCA (Dependent Care Account).
** Please submit this form to your HR department or payroll manager.
Enrollment Form - HSA
- To enroll in an HSA (Health Savings Account).
** Please submit this form to your HR department or payroll manager.
